The role of behavioural science in addressing Covid-19 challenges: Examples from local government

Deo, R., Nocco, L., Bateman, W., Baker, A.H., and Constable, M – Behaviour Change Unit, Hertfordshire County Council.

Covid has had an impact on all areas of wellbeing across the country, requiring a response both nationally and locally. There are a wide range of activities that have come under formal government legislation (i.e., Coronavirus Act, 2020) and regulations (e.g., The Health Protection regulations (Coronavirus restrictions, 2020) on how to reduce and prevent the spread of Covid-19 and minimise its impact. The role of behavioural science has been important in providing evidence-based guidance, frameworks and techniques to help drive appropriate behaviour change. This article provides examples carried out at Hertfordshire County Council (HCC) by a team of Behavioural Science Specialists in the Behaviour Change Unit (BCU). The BCU is an in-house, multidisciplinary team of behavioural experts that utilise data and the latest evidence in conjunction with robust behavioural frameworks, to improve public services, inform decision-making and deliver results for Hertfordshire residents and communities. Examples relating to businesses and vaccine uptake are provided to show how behavioural science can be integrated within the development of recommendations, guidance, and training to support Covid-19 management in the population.

Behavioural science support for disease prevention

Prior to the development and rollout of the vaccine, the main approaches to managing the prevention of Covid-19 in the general population were solely behavioural (i.e. social distancing, hand hygiene, and the wearing of face coverings) (Michie, et al., 2020). Understanding how to support compliance to these behaviours was key to successful disease prevention. A pragmatic approach was required to meet service needs and due to the speed of the response required, as the evidence base on Covid-19 was developing. This involved undertaking rapid reviews of the literature, to identify behavioural influences that could be used to design interventions to encourage sustainable changes in behaviour. The literature from other public health and behavioural science areas with a related evidence base (e.g. HIV and immunisations) were also reviewed, to provide insights to support the ongoing pandemic response.

The Behaviour Change Wheel framework (Michie, Van Stralen, & West, 2011) in conjunction with available and emerging evidence were used to map out influences on behaviour which were categorised by Capability, Opportunity, and Motivation (COM-B). This identified facilitators and barriers to health preventative behaviours, for example ‘general public wearing face coverings made of 2 layers of cloth when in public spaces outside of the home’ to reduce transmission of the virus. Suitable intervention functions (e.g. education, through infographic communications) were then selected to address barriers (e.g. a lack of knowledge about which settings face coverings should be worn in), and build on motivations to support compliance behaviours (e.g. protecting friends and family, or the NHS). This approach was used across a range of prevention behaviours including social distancing, hand hygiene and managing alcohol consumption during Covid-19.

Psychosocial skills manual for businesses

COVID-19 and the resulting economic volatility has had a significant impact on all businesses across the UK, and in particular, small and medium enterprises (SMEs). The pandemic has disrupted trading, including cash flow and supply chains; it has also brought substantial challenges for business owners, employers, and their workforce, including remote working, furlough, illness, increased workload and caring responsibilities. In turn this has resulted in significant detrimental effects on overall mental health and wellbeing (Cullen, et al., 2020; White, et al., 2020).

In an effort to prevent avoidable psychological morbidity, Hertfordshire Behaviour Change Unit and the UCL Centre for Global Non-Communicable Diseases joined forces with a key point of access for business support in the county, Hertfordshire Growth Hub. Their aim was to establish priorities for support, identify resources already available and any others required, in order to offer a programme of assistance. This work identified a clear need to support the mental health and wellbeing of business owners, and their employees, who were facing significant hardship and did not have access to traditional occupational health services often found in larger organisations. Key to this was the role of business advisors, who were supporting local businesses to manage the increasingly difficult challenges that they were facing.

The partnership’s working group collaborated to develop a psychosocial skills manual – ‘Wellbeing During Challenging Times’, and training for business advisors and local businesses. This aimed to give them the psychosocial skills, knowledge and confidence to have conversations about wellbeing and resilience with business owners and their employees. The topics included were communication skills (Motivational Interviewing; Rollnick & Miller, 1995), offering practical support in specific situations (including the Stop-Think-Go Model, IASC, 2020), how to signpost to relevant organisations and local services, as well as guidance on looking after your own wellbeing.

To extend the reach of this work a jointly funded (HCC/Local Enterprise Partnership) Wellbeing Coordinator was recruited to provide outreach to local businesses to support employers, business owners and those who advise them, to achieve and maintain good mental health and wellbeing. This was achieved through a range of initiatives including training frontline advisors to support clients to be proactive in raising the issue of wellbeing with their staff, and positioning wellbeing and good mental health as a key driver in increasing resilience and productivity.

Vaccine hesitancy script and training

The development of a vaccine was a critical step in battling the Covid-19 pandemic. However, one of the challenges has been ensuring enough people receive the vaccination across all sections of the population. Vaccine hesitancy is the observed delay in acceptance or refusal of vaccines despite their availability (Williams, et al., 2020). This poses a public health concern, as not accepting or refusing the offer of vaccination leads to lower immunisation rates and can cause a significant delay in the transition from the pandemic into recovery. In recent years public acceptance and uptake of vaccinations in general has fallen, and this has led the World Health Organisation to classify “vaccine hesitancy” as one of the top ten international threats to global health (World Health Organisation, 2014).

For this reason, Hertfordshire County Council created a team to develop a telephone contact programme for residents, to investigate the reasons behind any hesitancy and explore how to increase confidence in the vaccine. The BCU collaborated with the Vaccine Engagement Team to create a script for Engagement Officers to facilitate conversations with residents. This script focused on understanding people’s fears, issues and concerns around vaccination, as well as driving motivation to book or attend for vaccination. An important part of this was to ensure that this minimised the chances for unintended consequences (e.g., increasing concerns, or any emotional distress), by also enabling residents to voice their thoughts and feelings.

The design process began with a rapid review of the literature to understand the concept of vaccine hesitancy and ways in which it could be addressed. This led to a behavioural analysis of the problem (people not booking or attending an appointment), using the COM-B model of behaviour change to develop the script (Michie, Van Stralen, & West, 2011).

The script focused on addressing the core capability, opportunity and motivational barriers to vaccine uptake in residents who had not taken up an offer. This was not targeted at any specific demographic group, although the findings were useful for groups known to show greater resistance to accepting vaccinations.

Key barriers that were identified included:

• Everyday life getting in the way, and forgetting to attend appointments that they had booked, despite having every intention to attend (i.e. high motivation).
• Fear that vaccine side effects could cause people to be absent from work and face considerable financial pressures.
• Perceptions that one vaccine might be more effective and have fewer side effects than another.

Recommendations to address these barriers included i) sending out reminders prior to appointments, ii) acknowledging residents’ perceptions around employment issues and iii) providing balanced information and reinforcing the scientific credibility of the vaccine development process.

In addition to developing the engagement script, training was provided to the engagement team on the basics of behavioural science and the underlying concepts that informed the script. The script and training were both well received by the team and the recommendations have been accepted and implemented. The vaccine engagement officers are currently using the script when contacting people and they are recording all the necessary data to enable an evaluation of these activities to be completed by the end of 2021.

Reflections

Integration of behavioural science in addressing Covid-19 needs

At the core of the Government’s response to the Covid-19 pandemic is human behaviour, from social distancing to the wearing of face masks, from self-isolation to hand washing. As a local authority, enabling and supporting our residents and employees to enact these behaviours has been a priority, and behavioural science has provided a systematic and evidence-based way to do this. To ensure that a systematic approach was taken it has been imperative to carry out the following:

• Understand the client’s request
• Understand the problem and how it aligns to the current guidance
• Understand the desired outcomes
• Identify opportunities where behavioural science could help the client achieve the desired outcomes
• Identify the behaviours to target in order to achieve the desired outcomes
• Identify the influences on such behaviours

The application of behavioural science to the Covid-19 response has been approached in the same way as with any other project. However, the context of a pandemic where external influences upon individual behaviour are novel and evolving, where there is limited historic experience to draw insights from, and with limited time and resources to design and deliver behavioural interventions, presented additional challenges.

Implementation challenges

Although the human race has experienced various flu and plague pandemics in the past, Coronavirus was a novel strain, not previously identified in humans. Therefore, whilst learnings from SARS, MERS, and Spanish flu could have been extracted and applied, the quality of this evidence was variable, and specific knowledge and evidence about the nature in which Coronavirus operates, and how best to tackle the epidemic, was of course extremely limited at the start of the pandemic.

However, the main challenge was to produce, in a considerably short time span, good quality behavioural science resources and recommendations. These needed to be pragmatic, fit-for-purpose and easy to use by local authority colleagues, both internal and external. The challenge mainly originates from the fact that an applied and evidence-based behavioural science approach requires an in-depth preliminary analysis and understanding of the problem. This is key for two main reasons: to accurately strike the intended target, and to avoid any negative, unintended consequences.

Other challenges were around the frequent changes in government guidance and regulations, meaning that the team had to be responsive to this in engaging with clients in a clear and meaningful way. Taking into account residents’ perspectives and viewpoints is essential to promote greater engagement. This was done with a balance between using the academic literature, local insights and talking to professionals in the field. Ideally, insight would have been sought directly from residents in order to understand any additional barriers, but due to the fast-moving requirements in addressing the issue, this was not possible.

Ensuring that there is a balance between academic rigour, timeliness and delivery was essential in promoting efficacy, effectiveness, usability and engagement. As Behavioural Scientists, these challenges were addressed by adopting a flexible, agile approach – achieving the delicate balance between being scientific and being pragmatic.

Key learnings

Behavioural science has a place and offers great value in a time of huge uncertainty. As Van Bavel, et al. (2020) note, it has helped to navigate threat perception (emotion, risk perception, prejudice and discrimination, disaster and panic); social and cultural influences on behaviour (norms, political polarisation, inequality etc.); leadership (trust and compliance, in-group elevation, identity leadership); stress and coping (social isolation and connection, intimate relationships, healthy mindsets); science communication (conspiracy theories, fake news, persuasion); and individual and collective interest (e.g. moral decision making, cooperation etc.). As the country moves into recovery, it is evident that urgent global action is required to mitigate the potentially devastating effects of this pandemic, and behavioural science can be used to support policy making.

However, the above is not without nuances – for example, it was interesting to observe perceptions of behaviour change and psychology within the media and anecdotally. These perceptions were clustered into ‘enablers’ of citizen choice (e.g. handwashing, social distancing) versus ‘politicised restrictions’ of citizen choice (e.g. lockdown, social isolation). This led the media (and therefore general public) to question to what extent behavioural scientists were seen as working for the public good, rather than biasing the selection of evidence to suit political needs (Sanders, et al., 2021).

Benefits of integrating behavioural science

Understanding human behaviour and anticipating potential responses to changes in policies, messaging, and guidelines helped to increase performance of desired behaviours (e.g. mask wearing, vaccine uptake, social distancing in high streets, self-isolation). Furthermore, it ensured that a holistic approach to dealing with behavioural challenges was carried out based on a balance of strong empirical evidence and practical application. This provided the opportunity to work with and build on other skill sets within the local authority (e.g., communications, environment and highways and specialist public health functions such as public mental health).

Conclusion

Reflections on addressing Covid-19 within local government show the importance of supportive, passionate, and dedicated colleagues to protect the health of the population. This is not just for the job-related aspects of sharing knowledge, having someone to cast a critical eye over a literature review, or brainstorming possible interventions, but working cohesively, and developing as applied practitioners in addressing health behaviour needs. Local government provides an essential opportunity and location to develop recommendations and guidance, strategy, interventions and appropriate evaluation around current public health issues, and to improve population outcomes.

References

1. Cullen, W., Gulati, G., & Kelly, B. D. (2020). Mental health in the COVID-19 pandemic. QJM: An International Journal of Medicine, 113(5), 311-312.
2. Hertfordshire County Council. (2020). COVID-19 behavioural science resources. Hertfordshire County Council.
3. IASC. (2020, May). IASC Guidance on Basic Psychosocial Skills: A Guide for COVID-19 Responders. Inter-Agency Standing Committee.
4. Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6(1), 1-12.
5. Michie, S., West, R., & Amlôt, R. (2020). Behavioural strategies for reducing covid-19 transmission in the general population. BMJ Opinion, March 3rd.
6. Public Health England. (2020) The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020 No 350. legislation.gov.uk
7. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and cognitive Psychotherapy, 23(4), 325-334.
8. Sanders, J. G., Tosi, A., Obradovic, S., Miligi, I., & Delaney, L. (2021). Lessons from the UK's lockdown: discourse on behavioural science in times of COVID-19. Frontiers in Psychology, 12, 647348.
9. Van Bavel, J. J., Baicker, K., Boggio, P. S., Capraro, V., Cichocka, A., Cikara, M., ... & Willer, R. (2020). Using social and behavioural science to support COVID-19 pandemic response. Nature human behaviour, 4(5), 460-471.
10. White, R. G., & Van Der Boor, C. (2020). Impact of the COVID-19 pandemic and initial period of lockdown on the mental health and well-being of adults in the UK. BJPsych open, 6(5) e90.
11. Williams, L., Gallant, A. J., Rasmussen, S., Brown Nicholls, L. A., Cogan, N., Deakin, K., & Flowers, P. (2020). Towards intervention development to increase the uptake of COVID‐19 vaccination among those at high risk: Outlining evidence‐based and theoretically informed future intervention content. British Journal of Health Psychology, 25(4), 1039-1054.
12. World Health Organization. (2014). Principles and considerations for adding a vaccine to a national immunization programme: from decision to implementation and monitoring.